Barrier Against Infection: Importance and Challenges of Isolation Room Cleaning in Hospitals

Isolation room with young child and 2 health care workers in full PPE

(Adobe Stock 399949081 by chokniti)

Isolation rooms in hospitals are critical in controlling the spread of infectious diseases. Some of these spaces are specially designed to contain pathogens and minimize their transmission to other patients, health care workers, and visitors. The efficacy of isolation rooms hinges on their layout and usage protocols and stringent cleaning practices. This essay delves into the importance of isolation room terminal cleaning, emphasizing its role in infection control, the methodologies employed, and the challenges faced. The discussion is supported by peer-reviewed literature and seminal studies to highlight the significance of this practice in modern health care settings.

Infection Control and Prevention

Viruses and bacteria are the primary pathogens responsible for illness in the workplace. In severe cases, infections may necessitate hospitalization, making the hospital environment crucial for managing and controlling communicable diseases. Hospitals differ based on their construction era, funding sources, environmental context, and specialized services. The design and amenities of patient quarters vary according to the capabilities and resources available within each institution.

At the onset of the COVID-19 pandemic, the focus on isolation protocols became a critical measure for hospitals to control the spread of the virus and elucidate its transmission modes. Isolation rooms are essential for managing patients with
communicable diseases such as tuberculosis and COVID-19. Some of these rooms are meticulously engineered with precise infection control measures, including air recirculation and pressure differentials tailored to various pathogens’ transmission mechanisms. This ensures the safety of patients and health care personnel.

The practice of isolating individuals with infectious diseases has ancient roots as early as 1405 BCE. A small Middle Eastern religious community known as the Levites implemented quarantine measures and washing with running water to prevent the spread of diseases. These practices are documented in the biblical Book of Leviticus 13:46; 15:13.

Negative-pressure rooms are designated as such because the air pressure within them is lower than the outside air pressure. This pressure differential ensures that when the door is opened, potentially contaminated air or hazardous particles from within the room do not escape into adjacent noncontaminated areas. The filtered air is then either exhausted outside or recirculated after filtration to maintain a safe environment and prevent the spread of airborne pathogens.

Positive pressure isolation rooms are designed for patients with severe immunosuppression. In positive pressure rooms, the air pressure is maintained at a higher level than that of adjacent areas. This creates conditions to prevent the ingress of airborne contaminants, thereby protecting immunocompromised patients from potential exposure to infectious agents. The incoming air is typically high–efficiency particulate air (HEPA)–filtered to ensure a contaminant-free environment. Positive pressure rooms are also optimal during aseptic processes.

Contact isolation rooms are for patients with infections spread through direct or indirect contact. These rooms implement strict protocols to prevent the spread of pathogens through surfaces or physical interaction and do not rely on specialized air handling but emphasize stringent hygiene and personal protective equipment.

Droplet isolation rooms treat patients with infections transmitted via respiratory droplets, such as influenza, pertussis (whooping cough), and certain types of meningitis. They are designed to contain droplets within a confined space, reducing the risk of transmission to others in the health care facility.

By adhering to these specialized design and filtration protocols, isolation rooms significantly mitigate the risk of cross-contamination and enhance infection control within health care settings, thereby facilitating patient recovery. Hospitals constructed in earlier periods may lack the capacity to accommodate patients requiring clinically engineered isolation rooms. Therefore, adjunct portable equipment may be deployed to compensate for the absence of updated construction standards. Although engineering-controlled rooms isolate patients and provide barriers against potential hazards, isolation rooms must undergo rigorous cleaning and decontamination to prevent cross-contamination.

Cleaning Methodologies

Effectual cleaning protocols related to isolation quarters are pivotal. Pathogens can survive on surfaces for extended periods, posing a risk of indirect transmission. A study by Otter et al emphasizes that high-touch surfaces in hospital rooms can harbor pathogens like methicillin-resistant Staphylococcus aureus and Clostridium difficile, necessitating rigorous cleaning and disinfection practices to mitigate infection risks.¹

The CDC outlines specific steps, including using appropriate personal protective equipment (eg, gowns, gloves, masks) at the start of the cleaning process, cleaning from cleaner to dirtier areas, and using disinfectants effective against the targeted pathogens.

One standard approach uses a 2-step process: cleaning, followed by disinfection. This method involves removing organic matter and debris, which can inhibit the effectiveness of disinfectants. Disinfection then eliminates remaining pathogens. Conversely, the 1-step cleaning process utilizes a cleaner and disinfectant blend capable of removing soil and maintaining sufficient surface contact to achieve the intended spectrum of antimicrobial activity within the prescribed disinfectant dwell and kill time.

The importance of wall cleaning during terminal disinfection must be considered. Although walls in patient rooms may not exhibit visible contamination, they tend to accumulate particulate matter from patient skin desquamation after the high dusting procedure initiated at the onset of terminal cleaning. Charlotte Albina Aikens, an esteemed nurse and pioneer in hospital housekeeping, emphasized that dust in a hospital setting constitutes a significant hazard.² Aikens differentiated between domestic housekeeping and clinical cleaning protocols, instructing nurses and housekeeping staff that effective dusting involves the removal of dust with a damp cloth instead of a feather duster, which merely redistributes dust into the environment. As early as 1906, health care professionals acknowledged the effectiveness of damp-dusting walls and equipment in reducing pathogen transmission.² A study by Carling et al demonstrates that enhanced cleaning protocols, including using UV light and hydrogen peroxide vapor systems, significantly reduce pathogen load on surfaces, lowering infection rates.³

Importance of Training and Adherence

The effectiveness of isolation room cleaning heavily depends on the training and adherence of health care personnel. Appropriate training ensures that staff comprehend the value of thorough cleaning/disinfection and are proficient in using cleaning agents and equipment. Adherence ensures that these protocols are consistently followed.

Following the completion of cleaning procedures in isolation rooms, supervisors can employ advanced inspection tools, such as bioluminescence assays (ie, adenosine triphosphate [ATP]), to assess the presence of residual organic matter. However, it should be noted that ATP testing is not designed for viral detection. Additionally, supervisors may consider strategically placing fluorescent markers to detect gaps in coverage or utilize black lights to identify human secretions that are nearly imperceptible to the naked eye.

Understanding the conditions under which environmental services workers perform their duties is crucial. The stress associated with the constant pressure to turn over rooms frequently creates opportunities for inadvertent deficiencies in their work. The fear of disease during task engagement also plays a significant role in increasing anxiety levels among health care professionals.

To moderate the inherent anxiety within the supervisor-subordinate relationship, supervisors can periodically involve cleaning staff in the inspection process. This inclusive approach enables a debriefing session as an educational opportunity and a platform for continuous improvement and knowledge sharing, thereby enhancing team dynamics. Effective leadership methods are crucial in health care, as they significantly influence subordinate productivity. Chronic stress adversely affects the immune system, necessitating leaders to adopt measures to mitigate stress-inducing management practices to help reduce their subordinates’ vulnerability to infections. The resulting impact on productivity, whether positive or negative, directly affects the overall patient experience.

John Boyce, MD, director of Clean Hospitals, highlights the importance of regular training sessions and monitoring adherence to cleaning protocols.⁴ The study also underscores the role of environmental services personnel in infection control, advocating for their integration into the infection prevention team to enhance communication and adherence.

Challenges in Isolation Room Cleaning

Despite the critical importance of cleansing isolation rooms, several challenges persist. One is the emergence of pathogens with heightened resistance to disinfectants. Furthermore, the high patient turnover and the need for rapid room turnover can compromise the meticulousness of cleaning.

In their research, Weber et al discuss the difficulties in maintaining high cleaning standards in busy hospital environments.⁵ They suggest that innovative solutions such as automated disinfection systems and continuous monitoring technologies can help address these challenges. The study also calls for more research into developing effective, nontoxic disinfectants that can be used safely in health care settings.

Disposing supplies such as toilet paper and paper towels, which cannot be disinfected, is also imperative. Cleaning equipment, including housekeeping carts, mop handles, and other nonporous tools, should be thoroughly cleaned and disinfected following the treatment of an isolation room. Ensuring this protocol is essential to protect subsequent patients from exposure to the microbial flora of previous occupants, thereby promoting an environment conducive to healing.

Technological Advances

Recent technological advances have shown promise in enhancing the effectiveness of isolation room cleaning. Automated systems such as UV-C light and hydrogen peroxide vapor machines or US Environmental Protection Agency–approved electrostatic sprayers can provide more thorough decontamination of surfaces than manual cleaning alone. These technologies can reach areas that might be missed by manual cleaning and have been shown to significantly reduce the microbial load.

Rutala et al conducted a study on the effectiveness of UV-C light in decontaminating hospital rooms.⁶ Their findings indicate that UV-C light significantly reduces the presence of multidrug-resistant organisms on surfaces, supporting its use as a supplementary method to standard cleaning protocols. Suchtechnologies can enhance the overall infection control strategy by ensuring that isolation rooms are thoroughly decontaminated between patients.

Impact on Patient Safety and Health Care Costs

Effective cleaning and decontamination of isolation rooms directly impact patient safety and health care costs. Health care–associated infections (HAIs) are a significant burden on the health care system, leading to prolonged hospital stays, increased medical expenses, and higher morbidity and mortality rates. By preventing the transmission of infectious agents through rigorous cleaning protocols, hospitals can reduce the incidence of HAIs.

The same cleaning methodologies can be applied to surgical sites to mitigate disease transmission. In the US, surgical site infections cost approximately $20,000 per case.⁷ Joseph Lister, the father of modern surgery, pioneered using antiseptic wound dressings during surgical procedures as a supplementary measure against bacterial contamination in the surgical environment. His implementation of sanitary techniques was so successful that Listerine, the antiseptic product, was named in his honor. Initially marketed as a surgical antiseptic, the product became famous as a mouthwash.⁸

A cost-benefit analysis by Zimlichman et al⁹ reveals that reducing HAIs justifies investments in enhanced cleaning protocols and technologies. The study estimates that effective cleaning and disinfection practices can lead to substantial savings by decreasing the prevalence of infections that require expensive treatments and extended hospital stays.

Conclusion

Adherence to stringent cleaning protocols, the integration of advanced technologies, ongoing staff education, and psychoneuroimmunology in management are essential for upholding high standards of cleanliness and decontamination.As health care environments continue to advance, effective isolation room cleaning remains paramount. By improving terminal cleaning practices in isolation rooms, health care facilities can significantly bolster their infection control measures, control liability costs, and safeguard patients’ and health care personnel’s health and well-being.

References

1. Otter JA, Yezli S, Salkeld JAG, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control. 2013;41(suppl 5):S6-S11. doi:10.1016/j.ajic.2012.12.004

2. Aikens C. Hospital Housekeeping. London: FB & C Limited, Dalton House; 1906.

3. Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(1):1-7. doi:10.1086/524329

4. Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrob Resist Infect Control. 2016;5:10. doi:10.1186/s13756-016-0111-x

5. Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging healthcare-associated pathogens: Clostridium difficile, and Acinetobacter species. Am J Infect Control. 2010;38(5 suppl 1):S25-33. doi:10.1016/j.ajic.2010.04.196

6. Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol. 2013;34(5):467-469. doi:10.1086/670223

7. Mullen AN, Wieser E. Improvement of operating room air quality and sustained reduction of surgical site infections in an orthopedic specialty hospital. Am J Infect Control. 2024;52(2):183-190. doi:10.1016/j.ajic.2023.05.018

8. Our heritage—the history of the Listerine brand. Listerine Canada. 2024. Accessed July 26, 2024. https://www.listerine.ca/our-heritage

9. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046. doi:10.1001/jamainternmed.2013.9763